Ten Year Old Boy

 Jeanmarie Perrone MD, an emergency physician and medical toxicologist, answers questions from a reporter about the death of a 10-year- old boy in Miami and the dangers of fentanyl exposure.  Hers is a voice of reason in an understandable climate of hysteria.

Miami Boy's Death Shows Powerful Opioid's Chilling Potential

The case is tragic.  A 10-year-old boy walking home from the pool somehow encounters fentanyl and on arrival at home, vomits, collapses and dies, and later tests positive for fentanyl and heroin.

Miami chief: no leads, suspects in young boy's opioid death

Who knows what the final details of the case will be, but the facts of fentanyl exposure remain the same.  Dermal contact is highly unlikely to cause an overdose.  Injection, inhalation or ingestion are the areas of concern.

CDC: Protecting Workers at Risk

The boy did live in a neighborhood known as “ground zero” of the area’s opioid epidemic.  Could he have found heroin/fentanyl on his way home, and either touched the whitish powder (heroin is often cut with sugar or baby formula), and then conveyed it to his nasal membranes or eaten it?

I don’t know how heroin is packaged in Miami, but here is how it comes in Hartford.

Teach your children well.

Fentanyl Exposure: The Toxicologist's Take

 The American College of Medical Toxicology and the American Academy of Clinical Toxicology have issued a joint statement on Preventing Occupational Fentanyl and Fentanyl Analog Exposure to First Responders that states “the risk of clinically significant exposure to emergency responders is extremely low.”

The statement addresses reports of responders suffering overdose from handling or being in proximity to these opioids. Hopefully, this joint statement will help reduce some of the concern and hysteria caused by these stories, and prevent unnecessary delays in treating critical patients without endangering responders.

The statement reads:

“To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids. Incidental dermal absorption is unlikely to cause opioid toxicity.  Reports of emergency responders developing symptoms after contact with these substances have described nonspecific findings such as “dizziness” or “feeling like body shutting down”, “dying” without objective signs of opioid toxicity such as respiratory depression. Law enforcement and EMS must balance safety with mobility and efficiency when entering and securing potential scenes where drugs are used, distributed, or produced. We aim to address the risks of occupational exposures to ultra-potent opioids and the role of various types of personal protective equipment to reduce those risks."

The statement also emphasizes that Naloxone should only be “administered to those with objective signs of hypoventilation from opioid intoxication.”  (A recently issued report by the Drug Enforcement Administration had suggested giving Naloxone on first sign of symptoms.)

The full statement can be read here:

ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders

Here are their key recommendations:

General Precautions and Management of Exposure
● Workers who may encounter fentanyl or fentanyl analogs should be trained to recognize the symptoms and objective signs of opioid intoxication, have naloxone readily available, and be trained to administer naloxone.
● For opioid toxicity to occur the drug must enter the blood and brain from the environment. Toxicity cannot occur from simply being in proximity to the drug.
● Toxicity may occur in canines utilized to detect drug. The risks are not equivalent to those in humans given the distinct contact that dogs, and not humans, have with the local environment.

Dermal precautions
● For routine handling of these drugs, nitrile gloves provide sufficient protection.
● In situations where an enclosed space is heavily contaminated with a potential highly potent opioid, water resistant coveralls should be worn.
● Incidental dermal exposures should immediately be washed with copious amounts of water. Alcohol based hand sanitizers should not be used for decontamination as they do not wash opioids off the skin and may increase dermal drug absorption.

Respiratory precautions
● In the unusual circumstance of significant airborne suspension of powdered opioids, a properly fitted N95 respirator or P100 mask is likely to provide reasonable respiratory protection.

Mucous Membrane/Splash Exposure
● OSHA-approved protection for eyes and face should be used during tasks where there exists possibility of splash to the face.

Naloxone Administration and Airway Management
● Naloxone should be administered to those with objective signs of hypoventilation from opioid intoxication.
● If hypoventilation persists following initial naloxone dose and personnel with advanced airway training are not available, repeat naloxone until reversal is seen or 10 mg is administered.
● Personnel with advanced airway training should provide airway support for patients who are in extremis or those who do not improve with naloxone.

Long-term Sequelae of Exposure
● In the absence of prolonged hypoxia, no persistent effects are expected following fentanyl or fentanyl analog exposures. Those with small subclinical exposures and those who awaken normally following naloxone administration will not experience long-term effects.

Stay safe and use appropriate PPE.

Mother and Son

 

The woman with the cellphone stands outside the car. She explains that the male in the car has been smoking crack, taking benzos and doing heroin for several days. I ask if he is breathing. She says yes, but he is asleep right now. When she picked him at his friend’s house in their suburban town an hour earlier, he was out cold. His friends were going to give him Narcan, but the girl with them said don’t waste it. The girl then punched him hard twice in the chest and put ice in his pants.  I ask what is her relationship to the person in the car. He is my son, she says.

I approach the car. A heavily tattooed man wearing basketball shorts and an NBA jersey is fully reclined in the passenger seat. His mouth is open and his eyes are shut. I can’t tell if he is breathing. A police officer is standing next to me now. He opens the front door, I open the back door. A sternal rub and the man springs forward. “What? What the fuck!” he says. “What’s going on?” He is in his mid-twenties, a powerfully built thick necked young man with short hair and missing teeth. “What the fuck? Mom? Where did you take me? Hartford? The cops? Really? Mom, really?”

“You need help,” she says. “You need rehab, and your foot is infected.”

“My foot is infected. Yeah, my foot is infected. I’m a drug addict! Mom. Of course, it’s infected!”

The officer says, “I’ve dealt with you before. What’s your name?”

“Not me.”

“No, I’m sure I have.”

“It was probably my brother. We look alike. People mistake us.”

“Maybe.”

The mother says, “You need to let them take you to the hospital.”

“No, I’m not going to the hospital. You’re taking me back to my boyz. I can’t believe you did this?”

“I’m not taking you back. You either go to the hospital or you can walk home.”

“Walk home? It’s twenty miles! I don’t have socks. You’re going to leave me here on my own in Hartford without socks and shoes!”

“You have shoes right there.” I point to the sneakers by his feet.

“These aren’t my shoes! Jesus, Mom, you could have at least grabbed my socks!”

“Maybe its cause your feet are swollen.”

“I told you I’m a drug addict.”

“He injects in his feet,” his mother says. “He just got treated for an infection, but it’s worse.”

“Please, dude,” he says to the cop. “Make her take me back to my boys. That’s cold what she did.”

“It’s between you and your mom.”

“I don’t want you in my car,” she says. “I don’t want to see you anymore. I am done with you and your brother both.”

“Fine, but give me a ride back to my boys. You brought me down here now take me back!”

“Your mom wants you out of the car,” the officer says, “It’s her car. You have to get out.”

“But I have no socks. I have no socks! That’s not fair.”

“It’s not fair,” the officer says, “but you’re a man, you have to deal with it.”

“Mom, just take me back. Take me back to my boyz.”

“I can’t take this any longer,” the mother says.

“I have no fucking socks!”

This goes on for about fifteen minutes. It is like a symphony with repeating refrains and instrumentation. “I have no socks.” “I’m done with you.” “Be a man.” “I’m a drug addict!” “I can’t take this any longer!”

In between there are some actions. He knows where he is, the date and the president. He denies suicidal thoughts. He tries to light the butt of a cigarette found on the floor boards. His mom says he is going to kill himself. He misses all his rehab appointments. He apologizes for that, sincerely, he says, but says he is still not getting out of the car. She is worried about the fentanyl and the elephant drug. And she can’t spend her nights looking for him anymore. She is sixty years old, she says and she is tired.  Still not getting out of the car.  I tell his mom how to get Narcan by going to the pharmacy and getting the pharmacist to write her a prescription on the spot. Insurance will pay for it except for a small copay. She should always have it on her. But she doesn’t allow her sons in her house anymore, she says. But you’re still involved with them, I say. Yes, she nods, she is.

He says now he hasn’t eaten for days, we point to the hospital and say he can get a hot meal there, and he can get his foot looked at.

“I’m not going to the fucking hospital. I got to get back to my boyz!”

“All right, all right,” the mother finally says. “I’ll take you back to your boys if you just shut up. After that I’m done with you!”

The officer asks her if she is sure, if she feels safe with him.

“He is my son,” she says.

I tell her again how to get Narcan and to keep it in her purse.

She nods and says, she’ll do it.

She gets in the car. “Put your seat belt on,” she says to her son.

He shakes his head, but he puts the seatbelt on.

They drive off.

Fentanyl Skin Exposure: An MD's View

 A story published in Slate magazine yesterday questions the assumptions behind the widely reported episode of the Ohio police officer who required four doses of Naloxone after brushing Fentanyl off his shirt.

The Viral Story About the Cop Who Overdosed by Touching Fentanyl Is Nonsense

Written by Jeremy Samuel Faust, an emergency physician at Boston’s Brigham Young Hospital, the story discusses the case with noted toxicologists, including Dr. Ed Boyer of the Harvard Medical School, who says,  “Fentanyl, applied dry to the skin, will not be absorbed. There is a reason that the fentanyl patches took years [for pharmaceutical companies] to develop.”

 

 

The story mentions that the widespread coverage of the Ohio episode and others has caused the American College of Medical Toxicology to speed up the publication of their forthcoming position paper on Fentanyl Exposure.

We should all welcome the toxicologists’ entrance into the debate before the viral stories of “life-threatening” encounters cause any more hysteria.  To date, we have had to rely on the DEA’s warnings, which while well-motivated to protect responders, do not appear to be fully medically vetted.  They overstate the danger of skin contact and advocate for administering frequent doses of Naloxone to exposed responders who are not in respiratory depression.

In the meantime, wear your PPE, use due caution, and follow your existing medical protocols when dealing with possible opioid overdoses.

Fentanyl: A Briefing Guide for First Responders

 

Carfentanil (which had previously been seen in neighboring states) has now been officially identified in Connecticut.  The discovery of this drug 100 times stronger than Fentanyl poses questions: How much danger does Carfentanil (or Fentanyl for that matter) pose to EMS?  How can we in EMS protect ourselves from exposure to these drugs? What should an EMS responder do if they believe they are exposed or one of their coworkers has been exposed?

Every EMS responder should ask these questions and seek answers from both their medical control and from their services.  Unfortunately, I have had a hard time finding a one-stop source of good information on this question.  What follows is my attempt to share what I believe based on what I have read and people I have talked to.  It should not replace the information you get from your service.

Can Fentanyl or Carfentanil kill you?  Yes, they can.  If you inhale a certain amount of powder, you can go into respiratory arrest.  If no one gives you Naloxone or breathes for you with a bag valve mask, you may become the first EMS responder to die on the job as a result of accidental opioid exposure. 

Recently a police officer in Ohio fell ill after brushing white powder off his shirt,  The powder went airborne and he inhaled it.  It is unclear from news reports what exactly happened next.  The article below says the man passed out an hour later and had to receive four doses of Naloxone

Police officer overdoses and nearly dies after accidentally touching Fentanyl

This article suggests he collapsed within minutes of the exposure, which makes more sense.

‘I was in total shock’: Ohio police officer accidentally overdoses after traffic stop

Neither article are clear about whether or not the officer suffered respiratory depression.  I asumme that he did.

If you directly inhale powdered Fentanyl, particularly if you are opioid naive, you will likely overdose, depending on the amount you inhale.  It doesn’t take a lot.  A 0.1 gram single bag of east coast powdered heroin that may in fact not be  heroin at all, but Fentanyl cut with sugar or caffeine, or Carfentanil cut with substances, could be enough to kill you.  I have had experienced users tell me that last year a batch called Black Jack was strong enough that two users could get high off one five dollar bag.  If you find yourself in a situation where there is powder on your patient or in close proximity to you to the point that it has a chance of getting in your nose, you should have PPE on.  PPE should include nitrile gloves, eye protection, a N-95 respirator and it would be beneficial if you have long sleeves.  

What are the chances of getting powder up your nose?  Not great.  In 25 years of dealing with heroin overdoses, I’ve never gotten any powder up my nose.  But if only a few grains of Carfentanil can overdose you, that is not a chance I want to play with.  Better safe than sorry.

If you walk into a room that looks like a drug factory and everyone else is wearing gas masks and the air is thick with fumes, turn around and walk out.  If it is an ordinary overdose scene, use due caution.  Understand the difference between a hazmat situation and an isolated overdose scene where a substance user has overdosed from injection or snorting.

Carfentanil and Fentanyl can be absorbed through the skin, but that does not mean that simple contact with unbroken skin will instantly knock out a responder.  It won’t.  If you get the powder on your skin, wash it off.  While dry Fentanyl powder can be absorbed through unbroken skin, it takes hours to days, and requires fairly large amounts to affect you.   The more powder and the longer it is on the skin, the larger the risk.  Wash the powder off with water, not hand sanitizers, which may contain alcohol which can speed absorption.

The DEA recently released Fentanyl: A Briefing Guide for First Responders  that should be required reading.  That said, it seems to be written almost entirely for police and not so much for EMS and medical personnel.  

Take this passage:

Personnel should look for any cyanosis (turning blue or bluish color) of victims, including the skin or lips, as this could be a sign of fentanyl overdose caused by respiratory arrest. Further, before proceeding, personnel should examine the scene for any loose powders (no matter how small), as well as nasal spray bottles, as these could be signs of fentanyl use. Opened mail and shipping materials located at the scene of an overdose with a return address from China could also indicate the presence of fentanyl, as China‐based organizations may utilize conventional and/or commercial means to ship fentanyl and fentanyl‐related substances to the United States.

"Further, before proceeding"

If a patient is unresponsive and cyanotic, breathing 2 times a minute, unless they have fallen into a Scarface mountain of powder or any amount of powder that I think might compromise my ability to perform my duty of saving their life, I am going to put my gloves on, don my N-95 mask), grab my bag-valve-mask and start breathing for them.  I am most certainly not going to wait to treat the patient until after I have scoured the cluttered room for hidden packages from China.

Scene safety yes, but unless you are in a hazmat scene, letting a person die while you are looking for possible powder that undisturbed will not harm anyone, is misguided.  If on the other hand, everyone on the scene is either unmoving on the floor and the powder is so thick on the ground you can leave footprints in it, then I am going to turn around and exit.

But what if you are exposed?  What if when you turn your patient with agonal respirations over, you find powder on your exposed wrist or you simply start to feel dizzy on an overdose call.  What do you do if you feel you have been exposed and are starting to show symptoms.  Do you self-administer Naloxone or have your partner hit you with a dose of Naloxone?

Our medical guidelines call for Naloxone only to be used for patients who are in respiratory depression.  Do those same guidelines apply to exposed first responders?  According to the DEA booklet:

Overdose symptoms can include drowsiness, disorientation, sedation, pinpoint pupils, skin rash, clammy skin, and respiratory depression or arrest. The onset of these symptoms usually occurs within minutes.

If an exposure occurs, seek immediate medical attention as fentanyl and other fentanyl‐related substances can be very fast‐acting. In cases of suspected exposure, contact emergency medical services (EMS), or, if feasible, have EMS on scene prior to conducting enforcement activity. If an exposure occurs, remove the exposed individual from the contaminated environment (preferably to a location with fresh air). If they exhibit overdose symptoms, immediately administer naloxone by personnel trained in its use. Naloxone is an antidote for opioid overdose. Immediately administering naloxone can reverse an opioid overdose.

Depending on the drug's purity and potency multiple doses of naloxone may be required to stabilize the victim.  Continue to administer a dose of naloxone every 2-3 minutes until the individual is breathing on his/her own for at least 15 minutes, or until EMS arrives.

That’s a lot of Naloxone.  The way the passage is written, the person is getting at least 5 doses even though they are already breathing.  And do we need to be giving Naloxone to everyone who feels dizzy or clammy?  What does your medical control say?  Maybe it is just a poorly written passage.  And why no mention of using a bag valve mask?  If you are carrying Naloxone, you should also be carrying a bag valve mask.

From media reports, it looks like some responders are being given Naloxone based on onset of symptom.

Md. Officer Recounts Exposure to Heroin, Fentanyl on Overdose Call

This report describes the responder who was dizzy and had a high blood pressure and rapid pulse (opioids make your pressure and pulse rate go down not up) getting Naloxone right into the nose and the administrator not having time to attach the atomizer.

"I instantly felt very dizzy and I also felt like I was going to pass out, and I didn't want to pass out in the basement," Phillips said.

He got himself up to the kitchen and into a kitchen chair. The EMS workers hooked him up to monitor, which showed an elevated pulse and a blood pressure that was "ridiculously high."

Phillips took out a shot of Narcan, which Harford deputies and municipal police officers carry with them to revive overdose victims.

An EMS worker took the shot from him and administered it via his nose. Phillips said there was no time to put the "atomizer," which converts the Narcan from a fluid to a mist, on the end of the hypodermic, so the fluid was shot right into his nose.

He said the fluid gave him a "burning sensation," but "I didn't care, I just wanted the Narcan in me."

Maybe this is just an example of the press getting the story wrong.  But as reported, this person did not need Naloxone under standard EMS treatment guidelines.  And everyone, please be sure to take the time to attach the atomizer, otherwise the Naloxone will have difficulty crossing the blood brain barrier.  In other words, it won’t work, other than as a placebo if administered to a conscious patient concerned about overdosing.  As I mentioned, such a use would currently be against our medical control guidelines.

Here is another example of Naloxone being given for exposure.

Pa. Officer Exposed to Drug, Given Narcan

Read the new DEA guidelines for an understanding of the dangers Carfentanil and Fentanyl pose, but also hope for the development and distribution of guidelines by EMS medical directors for EMS personnel.  If a nationwide group of EMS physicians or even your medical control physician says administer Naloxone on first sign of exposure or first hint of symptom, then I will give that idea more credibility.  I don't expect they will.

As serious a threat as Carfentanil and Fentanyl pose to EMS, we need accurate news coverage of reported first responder exposure and and symptoms they develop, and we need medically reviewed and evidenced based guidelines on how we should respond. Otherwise, we may have hysteria.

In summary, think about things before they happen to you.  

What gear am I going to have on my when I go into a call for an overdose?

I am wearing nitrile gloves, eye protection, and I have a N-95 mask in my pocket ready for quick deployment.  Wearing your basic PPE should protect you.

What am I going to do if I get powder on my skin?

I’m going to wash it off for at least fifteen minutes.

What am I going to do if a first responder says to me, “I feel dizzy, hit me with some narcan, I think I’m going to die.”

I’m going to follow my current guidelines. I will monitor the patient and if he shows signs of respiratory depression, I will administer Naloxone per protocol.  If I have any doubt about administering Naloxone, I will call medical control.

How much Naloxone am I going to carry in my ambulance?

As much as my company will allow me to carry.  I have four milligrams in my in-house bag, and usually another four milligrams on the ambulance shelf.  I have never had to give more than 4 milligrams ( and is a rare exception) to reverse an opioid overdose (waiting 5 minutes between doses while bagging the patient).  Five minutes can seem like an eternity, but if you are effectively bagging a victim of opioid overdose, you just need to be patient.  That said, Carfentanil has been reported to require stronger doses of Naloxone, so we all may need to start carrying more Naloxone.

Stay safe, friends.